FLIGHT SAFETY FOUNDATION JULY–AUGUST 1996 FLIGHT SAFETY DIGEST SPECIAL DOUBLE ISSUE Dubrovnik-bound Flight Crew’s Improperly Flown Nonprecision Instrument Approach Results in Controlled-flight-into-terrain Accident Report Special CFIT Safety FLIGHT SAFETY FOUNDATION For Everyone Concerned Flight Safety Digest With the Safety of Flight Vol. 15 No. 7/8 July–August 1996 Officers/Staff In This Issue Stuart Matthews Dubrovnik-bound Flight Crew’s Chairman, President and CEO Improperly Flown Nonprecision 1 Board of Governors Instrument Approach Results in James S. Waugh Treasurer Controlled-flight-into-terrain Accident Robert Reed Gray, Esq. An analysis of the terrain profile, accident General Counsel and Secretary aircraft configuration and flight profile Board of Governors determined that the accident aircraft’s ground- proximity warning system would not have ADMINISTRATIVE provided a warning to the crew, the official U.S. Nancy Richards Air Force report said. Executive Secretary FINANCIAL FSF CFIT Checklist 26 Brigette Adkins Accountant Worldwide Commercial Jet Transport 30 TECHNICAL Accident Rates Declined in 1995 Robert H. Vandel There were nine fatal accidents in 1995 Director of Technical Projects compared with 14 in 1994, and the fatal-accident Ellen Plaugher rate was lower than in all but two years since Secretary 1960. MEMBERSHIP FAA Advisory Circular Outlines Ahlam Wahdan New Method for Designing Airport 34 Assistant to the Director of Membership and Development Pavement for Boeing 777 Book offers a new look at procedures for PUBLICATIONS avoiding midair collisions. Roger Rozelle Director of Publications MD-87 Crew Makes Mistaken Approach Girard Steichen To Military Airport 44 Assistant Director of Publications Rick Darby Sightseeing helicopter downed by fuel Senior Editor exhaustion at air show. C. Claire Smith Cover: Wreckage of aft fuselage and empennage at crash site of U.S. Air Editorial Consultant Force CT-43A (Boeing 737-200), Dubrovnik, Croatia, April 3, 1996. Photo: AP/Wide World Photos Karen K. Ehrlich Production Coordinator Flight Safety Foundation is an international membership organization Kathryn L. Ramage Librarian, dedicated to the continuous improvement of flight safety. Nonprofit Jerry Lederer Aviation Safety Library and independent, FSF was launched in 1945 in response to the aviation industry’s need for a neutral clearinghouse to disseminate objective safety information, and for a credible and knowledgeable body that would identify threats to safety, analyze the problems and recommend Jerome Lederer practical solutions to them. Since its beginning, the Foundation has President/Emeritus acted in the public interest to produce positive influence on aviation safety. Today, the Foundation provides leadership to more than 660 member organizations in 77 countries. Foreword In 1991, Flight Safety Foundation (FSF) launched an international campaign to reduce the number of controlled-flight-into- terrain (CFIT) accidents, which was expanded later to include approach-and-landing accidents. An FSF-led task force, in counsel with the International Air Transport Association (IATA) and the International Civil Aviation Organization (ICAO), was formed and set as its goal to reduce by 50 percent the number of CFIT accidents by 1998. The FSF CFIT Task Force, which in 1994 received an Aviation Week & Space Technology Aerospace Laurel award for its work, includes representatives from airlines, equipment manufacturers, airframe manufacturers, professional aviation organizations and other technical and research organizations (see page iii). CFIT accidents are the leading cause of commercial aviation fatalities. According to FSF CFIT Task Force statistics, CFIT and approach-and-landing accidents accounted for more than 80 percent of the fatalities in commercial transport accidents between 1979 and 1991. According to statistics compiled by McDonnell Douglas (see page 30), there were four commercial jet transport CFIT accidents in 1995. Approach-and-landing accidents in 1995 continued to be prominent among commercial jet transport accidents, with 20 such accidents worldwide. As part of the overall CFIT-reduction plan, the FSF CFIT Task Force has developed several products including: • An “FSF CFIT Safety Alert” distributed to thousands of operators worldwide at no cost to recipients that emphasized the importance of immediate and aggressive “pull-up” actions, unless circumstances (visual meteorological conditions and flight well-above flat terrain, for example) explicitly determined that a ground-proximity warning system (GPWS) warning was false. Early FSF CFIT Task Force findings had determined that flight crews in CFIT accidents often ignored GPWS warnings; delayed recommended pull-up procedures while trying to evaluate the accuracy of the GPWS warning; or failed to respond with sufficient aggressive pull-up action. • An “FSF CFIT Checklist,” which helps pilots assess CFIT risks for specific flights and operations. To date, more than 30,000 copies of the FSF CFIT Checklist (reproduced following page 25) have been distributed by the Foundation worldwide with the help of sponsorships from FlightSafety International, Scandinavian Airlines System (SAS) and SimuFlite Training International at no cost to the recipients. The English version remains available at no charge. Additional sponsorships are being sought to distribute Chinese, Russian, French, Spanish and Arabic versions of the CFIT Checklist, which were translated by ICAO. • A video training aid, CFIT: Awareness and Prevention, which examines several CFIT accidents and presents cockpit voice recorder (CVR) data and simulation to illustrate accident reduction strategies. More than 6,000 copies of the video were distributed worldwide in 1995 (4,500 at no cost, with major funding from Associated Aviation Underwriters (AAU), Gulfstream Aerospace and Jeppesen Sanderson). Copies of CFIT: Awareness and Prevention are available from the Foundation for US$30; and, • The CFIT Education and Training Aid, a two-volume training package developed under the auspices of the FSF CFIT Task Force and produced by the Boeing Commercial Airplane Group. Scheduled for release in late 1996, the training aid examines a number of CFIT accidents and focuses on human factors and management issues. The comprehensive training aid, which contains data to design simulator escape-maneuver training, is intended to be a resource for developing policies, procedures and CFIT-avoidance standards. The training aid also includes the video Controlled Flight into Terrain: An Encounter Avoided, which analyzes a jet transport CFIT accident in detail and shows how such accidents can be avoided. A price for the CFIT Education and Training Aid has not been determined, but it is designed to be an affordable training product for a wide range of aviation operators. FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • JULY–AUGUST 1996 i The FSF CFIT Task Force has also made eight recommendations to ICAO. A recommendation to broaden requirements for the use of GPWSs has been adopted by ICAO, and the others are under review. The new GPWS standards, effective Dec. 31, 1998, require GPWS in all aircraft used in “international commercial and general aviation operations, where the MCTM [maximum certified takeoff mass] is in excess of 5,700 kilograms [12,500 pounds] ... or that are authorized to carry more than nine passengers.” ICAO officials have indicated their support for the pending recommendations, which include: • A call for color-shaded depictions of terrain altitude on instrument-approach charts; • A warning against the use of three-pointer and drum-pointer altimeters; • A recommendation that all countries adopt the use of hectopascals for altimeter settings; • A call for the replacement of early-model GPWS equipment; • A recommendation for the improved design and presentation of nonprecision instrument approach procedures with a standard three-degree approach slope, except where prohibited by obstacles; • A call for the use of automated altitude call-outs; and, • A recognition of the important CFIT-avoidance benefits provided by the global positioning system/global navigation satellite system (GPS/GNSS). CFIT accidents involving commercial operators were examined in detail in a special April–May 1996 double issue of the Flight Safety Digest. The research focused on 156 CFIT accidents that occurred from 1988 through 1994. The report, “An Analysis of Controlled-flight-into-terrain (CFIT) Accidents of Commercial Operators, 1988 through 1994,” concluded that 75 percent of the 108 accident aircraft (for which data were available) were not equipped with a GPWS and that landing (descent)-phase and landing (approach)-phase accidents together accounted for nearly 70 percent of all CFIT accidents studied. The report also noted that nearly 60 percent of landing (approach)-phase accidents involved aircraft flying nonprecision approaches. Twenty- five percent of the approaches were very high frequency omnidirectional radio range (VOR) DME approaches. Another FSF report, prepared for the Directorate-General of Civil Aviation of the Netherlands and published in the March 1996 Flight Safety Digest, determined that there was a “five-fold increase in accident risk among commercial aircraft flying nonprecision approaches compared to those flying precision approaches.” The report, “Airport Safety: A Study of Accidents and Available Approach-and-landing Aids,” said that the “chance for error by the crew is probably greater during a nonprecision